Thiruvengadam Muniraj, MD

YNHH gastroenterologist first in Connecticut to perform endoscopic ultrasound procedures

Yale New Haven Hospital remains at the forefront of surgical advances with the successful completion of two endoscopy procedures performed in Connecticut for the first time.

Gastroenterologist Thiruvengadam Muniraj, MD, director, Yale Center for Pancreatitis, recently performed an endoscopic ultrasound (EUS)-guided hepaticogastrostomy and EUS-guided pancreaticogastrostomy. Both procedures allow physicians to remove obstructions and perform procedures to help bile and pancreatic fluids drain, without patient discomfort. The EUS-guided procedures are used when a traditional endoscopy approach isn’t feasible.

The EUS-guided hepaticogastrostomy helps doctors avoid obstructions that prevent them from working on blocked pancreatic bile ducts. “A lot of patients with pancreatic cancer get jaundice because the bile duct gets blocked,” Dr. Muniraj said. “We perform an ERCP (endoscopic retrograde cholangio-pancreatography) to get inside the bile duct and see if we can relieve the obstruction by stenting the duct.”

Traditionally, physicians would use an endoscope to enter the stomach, the small intestine, then the bile duct to place the stent. However, in some patients that isn’t possible. For example, advanced pancreatic cancer can create a small intestinal (duodenal) obstruction that prevents an endoscope from reaching the bile-duct opening, Dr. Muniraj explained.

Traditionally, the gastroenterologist would refer the patient to an interventional radiologist to insert a tube that drains bile out through the skin and into a bag. With the EUS procedure, the endoscopy team uses ultrasound to visualize a different route for the endoscope so the bile duct can be drained internally, into the stomach.

“It’s completely internal drainage, which is preferable, and better for the patient’s quality of life” Dr. Muniraj said.

The procedure can also help patients go back on chemotherapy, since good bile drainage is essential for patients to successfully metabolize chemotherapy drugs.

Dr. Muniraj also performed an EUS-guided pancreaticogastrostomy on a YNHH patient who had several episodes of acute, recurrent pancreatitis.

The patient had an isolated pancreas that was disconnected from the gastrointestinal tract. Instead of removing part of the pancreas or connecting it to the small intestine, Dr. Muniraj inserted the endoscope through the stomach. Endoscopic ultrasound was used to scan the disconnected pancreatic duct through the stomach wall, allowing Dr. Muniraj to puncture the duct so it could drain directly into the stomach via a stent. The procedure prevented further pancreatitis attacks.

These minimally invasive, complex EUS procedures are rare nationwide, with just a handful of U.S. hospitals performing them.

“These procedures require an endoscopist and full team with a great deal of technical expertise, along with the proper instruments and technology,” Dr. Muniraj said. “The Center for Advanced Endoscopy is at the cutting-edge in terms of offering this level of technology and expertise.”